“At the inquest it was evident that the deceased had suffered with clostridium difficile…”
Dated 16 Nov 2018, from the coroner for Stoke-on-Trent and North Staffordshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 25 Apr 2019, after the 56 days for replies had ended (11 Jan 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated16 Nov 2018
- Deadline11 Jan 2019
- Published on judiciary.uk25 Apr 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 25 Apr 2019, after the 56 days for replies had ended (11 Jan 2019). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (1) At the inquest it was evident that the deceased had suffered with clostridium difficile diarrhoea. It was accepted by the patient and the family that she needed to be nursed in a single room. However in her case it was for a very prolonged period. The social isolation had a very significant impact on her health and well-being and was a factor in her failure to recover. No policy appears to be in place for referral to mental health services in such circumstances. Referral in this case was prompted by the family. (2) There was evidence that meals were delivered by an independent company called Sodex. The family frequently observed this company giving out and collecting meal trays. Despite this medical records appeared to have been completed daily by nursing and health care staff recording adequate nutrition. Given this situation how is it possible to reconcile the nursing records with the practice of the catering team distributing and collecting meal trays? (3) The deceased lost weight. There was no referral to a dietician until prompted by the
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2018-0355
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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